Measuring trust: a precursor to resilient health systems

Trust, a starting point for everything from adherence to public health measures to vaccine uptake, is dwindling for governments and public institutions. To instil better trust and design better policies, first we must find better ways of measuring it

Public trust helps societies and economies function well. Trust builds institutional legitimacy for government policies and leads to greater compliance with regulations and responses to crises, as well as with health policies.

The Covid-19 pandemic clearly demonstrated this. Trust affected adherence to recommended public health measures and was a key determinant of health system resilience. Trust in institutions was associated with improved pandemic outcomes, including compliance with containment and mitigation measures, contact tracing and perceptions about governments’ preparedness for the next health crisis. People’s willingness to be vaccinated, too, is correlated with trust in the ability of scientific and public institutions to guarantee the safety and efficacy of vaccines, and to implement vaccination programmes equitably and effectively.

Taking tangible steps

Despite its centrality, many countries observed declining levels of trust in government, and in health system capacity to handle the crisis and implement coherent policies during the Covid-19 pandemic. So, what can be done?

The first priority is to measure trust better, particularly trust in health systems. Although there are various broad measures of trust in government, robust measurement of trust in health systems is not systematic. As part of its ‘Living, Working and Covid-19’ e-survey, Eurofound collects data on people’s trust in the healthcare system in Europe. The OECD Trust Survey 2023 also provides insights into public perceptions of government institutions’ capacity to protect people’s lives, including in the face of a large-scale emergency.

Importantly, measurement has focused on trust in health systems’ ability to deliver services or protect against risks, but falls short of assessing health systems’ capacity to meet people’s needs and expectations.

To date, measurement of health system performance has considered primarily what providers do, rather than what people need, and failed to incorporate patients’ voices, outcomes and experiences in a systematic way. A more granular assessment of trust beyond aggregate ‘trust in health system’ is therefore needed that includes patients’ reported measurement of outcomes and experiences of health systems, as well as their assessment of trust in care providers.

The results of the forthcoming Patient Reported Outcomes Surveys, spanning over 100,000 patients in 19 countries, is capturing data on people’s trust in both health systems and their current care provider. With this data, it will be possible to connect levels of trust with patients’ outcomes, experiences and capabilities, as well as the characteristics of their healthcare provider, to provide insights on how policies can be designed to enhance trust and its related benefits.

What comes next

Measurement of trust is a starting point, but policy action should not stop there. Trust is a multifaceted concept. Building and sustaining trust requires multipronged policy approaches and clear political focus. This is critical in a world where trust is dwindling. The OECD Trust Survey shows that in 2023, around four in 10 people had high or moderately high trust in their government, while a higher share (44%) had no or low trust. So, what can be done?

First, trust in health systems is interlinked with broader trust in governments, and cannot be built in isolation from wider efforts to strengthen trust in governments. Such trust is critical for the effective functioning of institutions and the acceptance of public policy, both during crises and in normal times.

Second, trust requires action based on the core principles that populations expect should guide public policy. One is fairness. The extent to which health systems deliver equitable health outcomes for populations at large, and apply consistent treatment for all, is key in order to maintain public confidence in health services. Another principle is integrity: the extent to which health systems use resources ethically, follow ethical standards in medical education and practice, and apply integrity standards to procurement of medical goods and products. An additional principle is openness, namely the effectiveness in fostering public engagement and maintaining public confidence, including through transparent communications as unexpected events or crises arise, and through trust in science.

Third, building trust requires rethinking health system financing, technology adoption and service organisation, to be better centred on what people need. This is not happening yet. Only a few countries involve patients systematically or institutionalise people’s involvement in key health policy decisions. To build trust, governments need to deliver to citizens the services they need, at the standard they expect.

People need to receive high personal attention, be treated with respect, and be consulted about and engaged in their care.

These actions cannot be an afterthought to crises. Without focused measurement and decisive policies to build trust, resilient health systems will remain out of reach. And, in the longer term, trust is also vital to nurture political and citizen participation, strengthen social cohesion and tackle long-term societal challenges linked to health systems performance – be it climate change, ageing populations, the use of digital technology, pandemic preparedness and more.